Programs

Overview


MD Value Care offers tailored care coordination programs to assist Medicare patients with chronic condition management. Some of the most common chronic conditions among Medicare patients include diabetes, high blood pressure, heart failure, chronic obstructive pulmonary disease, and asthma.

Our Care Coordination Programs help patients who have one or more chronic conditions gain the knowledge, skills, tools, and confidence to become an active participant in their care and achieve their health goals.

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Engage: Managed Care Between Visits

Designed to help patients manage their care between office visits, this program provides personalized coaching, education, and evidence-based interventions to enhance outcomes for Medicare patients. Patients will meet with registered nurses, social workers, and registered dietitians along their journey to improved health. Focus areas can include nutrition, activity, lifestyle and other social behaviors, condition knowledge, self-management, and medication adherence.

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CareBridge: Transitions from Hospital to Home

Designed to help Medicare patients and their families feel better prepared for the transition from hospital to home, CareBridge offers coaches who serve as a guide and work to ensure that all needs are met. This program consists of one home visit and a series of follow-up phone calls focused on: addressing post-discharge questions and concerns, understanding medications, and increasing awareness of “red flags” that point to a worsening condition. Our coaches help with preparing for follow-up appointments, creating a personal health record, and supporting patients in their personal health care goals.

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Pathways: Chronic Disease Management

The Pathways suite of programs was built to meet the needs of patients with chronic comorbid conditions and help them live with their conditions. The programs are currently focused on heart failure, chronic obstructive pulmonary disease, diabetes, and asthma.

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Beacon: End of Life Planning

Designed for patients with advanced illnesses, this program is centered on patient choice and focuses on ensuring that physical, mental, social, and spiritual needs are met.  Through a compassionate, person-centric approach, our coaches deliver a set of evidence-based, standardized interventions to support patients and their caregivers during the end of life process.

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Coming Soon: Annual Wellness Visit Program

Please check back soon!

Meet Our Team

Our interdisciplinary team of experienced patient navigators and certified health coaches serves as an extension of the provider’s practice staff to provide additional care to Medicare patients. This team will work with patients to help them gain the knowledge, skills, tools, and confidence to become an active participant in their care and achieve their health goals.

Diane Gilkenson, RN

Diane has over 40 years of experience in all kinds of clinical settings and as a community-based health coach. Most recently, she has focused on geriatric care, providing nurse navigation in primary and specialty care medical practices throughout the Richmond area.

Suzanne Jencik, Outreach Specialist

Suzanne has several years of experience working in health and wellness. As the Outreach Specialist for MD Value Care, she calls eligible patients and enrolls them in our life-enhancing programs. She has experience in several office practice settings, as well as business experience as an owner and manager of a convenience store.

Mary Krakoviak, RN

Mary graduated from Barton College in North Carolina with a Bachelor of Science degree in nursing. She also completed a course on Parish Nursing. Mary has 40 years of nursing experience in Public Health for over 5 years and Home Health Care for 25 years. She worked as a Health Coach and as a Nurse Navigator for Patient Centered Medical Homes. She has been a Certified Case Manager (CCM) since 2014.

 

14600+
Patients
445
Providers
33
Quality
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